AccountId: 011433970860
ContactId: 27262dd4-b1f5-42d0-8141-7a7db019e70d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1186890 ms
Total Talk Time (AGENT): 309221 ms
Total Talk Time (CUSTOMER): 334240 ms
Interruptions: 5
Overall Sentiment: AGENT=0.2, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/19/27262dd4-b1f5-42d0-8141-7a7db019e70d_20250319T14:26_UTC.wav
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[AGENT][NEUTRAL] For calling APL, this is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, [PII]. I'm calling regarding um
[CUSTOMER][NEUTRAL] A claim for one of my clients that she's appealing.
[CUSTOMER][NEUTRAL] And I wanna find out, um.
[AGENT][NEUTRAL] Can I have your name and a callback number?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII], and the callback number is [PII].
[AGENT][NEUTRAL] [PII], are you calling from a provider's office?
[CUSTOMER][NEUTRAL] A broker, a broker, sorry.
[AGENT][NEUTRAL] Broker, what's the name of the company?
[CUSTOMER][NEUTRAL] Associated financial consultants.
[AGENT][NEUTRAL] And what is your policy number of the member?
[CUSTOMER][NEUTRAL] Policy number.
[CUSTOMER][NEUTRAL] Sorry, give me one moment.
[AGENT][NEUTRAL] Could you provide me with the spelling? Mhm.
[CUSTOMER][NEUTRAL] 197.
[CUSTOMER][NEUTRAL] OK, the policy number is 19, uh-huh.
[AGENT][NEUTRAL] 197.
[CUSTOMER][NEUTRAL] 971 8.
[AGENT][NEUTRAL] What is the member's name and date of birth?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And her date of birth, give me one moment, let me pull that one.
[CUSTOMER][NEUTRAL] Sorry.
[AGENT][POSITIVE] Sure, take your time.
[CUSTOMER][NEUTRAL] Which it was Friday, girl. I'm done, my God.
[CUSTOMER][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] OK, let me, let me log into.
[AGENT][NEUTRAL] Provide me with the spelling of your name while you're pulling it up.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And what's the first initial of your last name?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Her date of birth is [PII].
[AGENT][NEUTRAL] And what is her date of service?
[CUSTOMER][NEUTRAL] The date of service is [PII]. I have a claim number.
[AGENT][NEUTRAL] What's your claim number?
[CUSTOMER][NEUTRAL] 353-791-6
[AGENT][NEUTRAL] Is there a particular date of service because there's multiple claims, multiple dates of services for this client.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] It is the date of service is [PII].
[AGENT][NEUTRAL] For the hospital charge?
[CUSTOMER][NEUTRAL] She's Miami Cancer Instit.
[CUSTOMER][NEGATIVE] In that APL denied.
[AGENT][NEUTRAL] So we have, I see one for the Baptist Hospital for [PII].
[AGENT][NEUTRAL] What is the bill amount?
[CUSTOMER][NEUTRAL] This was her
[CUSTOMER][NEUTRAL] OK, let me, let me find it. Um, this was for tattooing. She had breast reconstruction.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] 9
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, hold on.
[CUSTOMER][NEUTRAL] OK, it is.
[CUSTOMER][POSITIVE] Yeah, the, the, let me, oh wow.
[CUSTOMER][NEUTRAL] OK. According to this, it says the bill for Miami Cancer Institute says total charges 1940.
[CUSTOMER][NEUTRAL] Insurance adjustment 170,720. Her balance due 23,280.
[AGENT][NEUTRAL] 7916.
[AGENT][NEUTRAL] So
[AGENT][NEGATIVE] She probably should have like they denied it for something.
[AGENT][NEUTRAL] It's not a sickness.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] Give me that claim number again.
[CUSTOMER][NEUTRAL] The claim number.
[CUSTOMER][NEUTRAL] Is 353.
[CUSTOMER][NEUTRAL] 7916
[AGENT][POSITIVE] OK that's great.
[AGENT][NEUTRAL] Let me pull it up.
[AGENT][NEUTRAL] So.
[AGENT][NEUTRAL] 22.
[AGENT][NEUTRAL] Not being a sickness.
[AGENT][NEUTRAL] 94.
[AGENT][NEUTRAL] 94.
[AGENT][NEUTRAL] 94 OK.
[AGENT][NEUTRAL] 857.
[AGENT][NEUTRAL] Bear with me. I'm checking history of a couple of things.
[AGENT][NEUTRAL] So this is from the Baptist.
[AGENT][NEUTRAL] So the Baptist Hospital.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Right, which is part of Miami Cancer.
[AGENT][NEUTRAL] So, the reason why I was denied, I'm not sure if they expressed the reason why I was denied, but it's saying is it was denied due to the, the diagnosis code.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEGATIVE] It's breast cancer.
[AGENT][NEUTRAL] No, the diagnosis code states encounter for screening.
[AGENT][NEUTRAL] That's not, so what you would need to do is contact her, the facility, the billing department to actually see if they coded it wrong cause they may have coded it wrong cause right now it looks like this is not considered as a sickness. It just says encounter for screening unspecified.
[CUSTOMER][NEUTRAL] What?
[AGENT][NEUTRAL] She has an ICDT so mhm.
[CUSTOMER][NEUTRAL] OK, hold on, let, let me find the claim, OK, give me one moment, let me find the claim that was, let me see because usually I keep copies of the claim. OK, when I called APL.
[CUSTOMER][NEGATIVE] They specifically told me that it was denied because of the service, that it wasn't covered, tattooing wasn't covered.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] No, it's denied because of the ICD code, the ICD code. So I'm not sure who you spoke with in the beginning. However, what I'm showing is that the, the claim was denied due to it not being a sickness, a screening encounter of a screening of unspecified is not considered as a sickness, so she may wanna reach out or you can reach out to the facility to verify if they coded it correctly because as of right now it's.
[CUSTOMER][NEUTRAL] They didn't tell me anything about the diagnosis.
[CUSTOMER][NEUTRAL] Well, that, they didn't tell.
[CUSTOMER][NEUTRAL] OK, OK. OK.
[AGENT][NEGATIVE] It's not gonna be covered because it's not considered as a sickness.
[CUSTOMER][NEUTRAL] OK, hold on, let, let.
[CUSTOMER][NEUTRAL] Let me, yeah, because they told me she had to do an appeal letter, so she wrote.
[CUSTOMER][NEUTRAL] A letter in [PII] and mailed it appealing the claim, saying it was a tattoo due to she had to have a breast reconstruction.
[CUSTOMER][NEGATIVE] And what have you, but then the strange thing is is that she mailed that letter to you guys and got no response.
[CUSTOMER][NEUTRAL] So you get an appeal letter and you don't respond.
[AGENT][NEUTRAL] Well, it, we don't get the appeal letter. It goes to the appeal department, not the claims department. But once they received the appeal, I'm not sure how long the process is. However, once they're done with reviewing everything, then she would definitely get a response. It's not that they're ignoring her.
[CUSTOMER][NEUTRAL] Right, right, right, right, right. Exactly. But
[CUSTOMER][NEUTRAL] So you think they haven't finished reviewing it?
[AGENT][NEUTRAL] If she hadn't received any type of response, then I'm
[CUSTOMER][NEUTRAL] I'm just asking.
[CUSTOMER][NEUTRAL] No, she hasn't.
[AGENT][NEUTRAL] To me, it sounds like they have not.
[AGENT][NEUTRAL] Gotten done re reviewing it, but I'm telling you what the issue is with the claim because I work in the claims department.
[CUSTOMER][NEUTRAL] Really?
[AGENT][NEUTRAL] As of right now, the claim from the [PII] is for ICD code that's not considered a sickness, which is Z as in zebra 13.9.
[CUSTOMER][NEUTRAL] No, no, yeah, I know.
[CUSTOMER][NEGATIVE] And there's no way to find out what the status of the appeal is because I, I just don't want her to keep going through all these circles if.
[AGENT][NEUTRAL] But, right, but I'm telling you what she, I'm suggesting what she should do, being that I am a claims adjuster and I'm telling you that what's the reason for the denial. So she needs to contact them to verify if it actually was coded correctly cause that could be possibly it may have been coded incorrectly.
[CUSTOMER][NEUTRAL] OK, hold on, let me, let me see, I'm trying to pull up the claim.
[CUSTOMER][NEUTRAL] Oh that's a confirmation. Hold on one moment.
[AGENT][NEUTRAL] Like the reason that she's getting it is because she had breast cancer, correct? And then reconstructing her breast. That would be to me, if I was a coder, that would be the reason she's, she's here because she has breast cancer. We had to reconstruct her breast. That is the valid reason because of breast cancer, but they don't have that on there. They have 13.9.
[CUSTOMER][POSITIVE] Right. Correct.
[CUSTOMER][NEUTRAL] Let me see, I'm, I'm trying to pull, let me see if I have what they put.
[CUSTOMER][NEUTRAL] So I show here.
[CUSTOMER][NEUTRAL] That the code was [PII].
[AGENT][NEUTRAL] It's still is considered as, it's not a sickness.
[CUSTOMER][NEUTRAL] I don't know what that is, but
[AGENT][NEUTRAL] But the code that we have on the 1500 that was sent over by the Baptist.
[AGENT][NEUTRAL] It says Z13.9.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, but the Z42.1 is for breast reconstructuring following mastectomy.
[CUSTOMER][NEUTRAL] And that's what was on the claim when it was submitted.
[AGENT][NEUTRAL] That's not on the claim that we received. We can't change anything. We only received the information that's sent over to us.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK. I submitted the claim for her. Is there any way you could pull the claim that I submitted for her because
[AGENT][NEUTRAL] I'm looking at the claim.
[CUSTOMER][NEUTRAL] Is on page one of two and it's highlighted in yellow and it says ICD code Z42.1.
[CUSTOMER][NEUTRAL] Cause I don't know if the hospital submitted a claim as well, maybe, right?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I don't know. I'll tell you what, mm.
[CUSTOMER][NEUTRAL] Let me tell you what day we submitted the claim.
[CUSTOMER][NEUTRAL] Sorry. Um,
[CUSTOMER][NEUTRAL] The claim was submitted on [PII].
[CUSTOMER][NEUTRAL] And it has a diagnosis code on there.
[AGENT][NEUTRAL] What's the name of the company you work for?
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Associated financial consultants for the broker.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, I, I file her claims.
[AGENT][NEUTRAL] Bear with me while I pull up everything.
[CUSTOMER][POSITIVE] Sure, no problem.
[CUSTOMER][NEUTRAL] Oh my [PII].
[CUSTOMER][NEUTRAL] Yeah, usually you guys respond so fast, like I said this one was.
[CUSTOMER][NEUTRAL] Submitted on on December and.
[AGENT][NEUTRAL] And when did you say you submitted the claim? You submitted the information in so I can make sure that I'm pulling the correct information.
[CUSTOMER][POSITIVE] All [PII]
[CUSTOMER][NEUTRAL] It was submitted on [PII] at [PII] and I have the confirmation number from the portal.
[AGENT][NEUTRAL] 12.
[AGENT][NEUTRAL] OK, that's the one that's that's the one that I'm under.
[AGENT][NEUTRAL] 8857.
[CUSTOMER][NEUTRAL] I'm sorry.
[AGENT][NEUTRAL] And you said what page it was on for the information that you submitted?
[CUSTOMER][NEUTRAL] I'm sorry.
[CUSTOMER][NEUTRAL] OK, it was on page, oh shoot, hold on, sorry, sorry.
[CUSTOMER][NEUTRAL] It was on page, page 1 of 2 of the Miami Cancer Institute. It's in yellow.
[CUSTOMER][NEUTRAL] On page 13.
[AGENT][NEUTRAL] I'm scanning through the pages to verify.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] If something was highlighted in yellow.
[CUSTOMER][POSITIVE] No problem.
[AGENT][NEGATIVE] Was there 16 pages you sent over 16 pages?
[CUSTOMER][NEUTRAL] No, I have, well, I have 14. I'm not sure, 16, but I have 14.
[CUSTOMER][NEUTRAL] And it was page 1 of 2 of the Miami Cancer Institute request for payment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Which was like the last two pages of the attachment.
[AGENT][NEUTRAL] Yeah, it's, it's the last day before the.
[CUSTOMER][NEUTRAL] Oh, you see it?
[AGENT][NEUTRAL] Information page, I do.
[AGENT][NEUTRAL] I'm gonna get the adjuster to look at this and kind of breast.
[AGENT][NEUTRAL] And um
[AGENT][NEUTRAL] Then someone will give you, they will reprocess it or give you a call back. What is a good call back number for you, the [PII].
[AGENT][NEUTRAL] 6 number.
[CUSTOMER][NEUTRAL] Well, yeah, they can call me here. Yeah, it's my cell cause I'm working from home.
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Because if you call the office it's [PII] if you call the office it's gonna go to voicemail and have to call back.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm gonna let the adjuster look at this and then we'll reach back out to you.
[CUSTOMER][NEUTRAL] Alright.
[AGENT][NEUTRAL] And I'll let you know if it needs to be if they're gonna reprocess it.
[CUSTOMER][POSITIVE] OK awesome.
[CUSTOMER][POSITIVE] OK awesome thank you so much.
[AGENT][POSITIVE] You're welcome. Is there anything else that I can assist you with today?
[CUSTOMER][POSITIVE] No, that's it. Thank you. Have a nice day.
[AGENT][POSITIVE] Thanks for calling APL. You have a great one as well. Good bye.
[CUSTOMER][NEUTRAL] You too. Bye-bye.